Neurofibroma of saphenous nerve mimicking thrombophlebitis

Young man (25 yrs) complained of persistent pain on the medial side of the lower part of the left thigh. A cord like structure with 3 small nodular thickenings was palpable parallel to the course of the great saphenous vein. Initially in a he was treated as case of superficial thrombophlebitis of the great saphenous vein in private clinic near his home. But when the pain persisted even after receiving local therapies and Injection Heparin (LMWH) he is referred to the vascular surgery unit in our hospital. Duplex scan of the thigh reported it as thrombophlebitis of a vein parallel to the great saphenous vein. We continued Injection Heparin and suspected thrombophilia. The pain persisted and on further detailed examination of swelling we noted nodular swellings over a cord like structure. He did not give history of risk factors for thrombophlebitis. We considered biopsy of the cord with nodules to confirm a diagnosis. The excised cord with nodular structure was sent to histological examination. It was confirmed as “Neurofibroma” of the saphenous nerve. Post operatively the pain subsided dramatically and patient was discharged with an advice to attend the follow-up clinic. Diagnosis of small tumors of peripheral nerve at this site can be mistaken as a case of thrombophlebitis and there may be undue delay in diagnosis as we do not perform biopsy for thrombophlebitis in routine clinical practice. Unusual pain, nodular feeling of the swelling in this case helped us to consider early biopsy and excision of the tumor.

Excision of infected PTFE graft from the neck.

Subclavian artery aneurysm is rare. Young man (20yrs) developed right subclavian artery aneurysm after blunt injury. Aneurysm was repaired with saphenous vein but thrombosed. So, it was replaced by PTFE graft. After 3 months PTFE graft also occluded.

A sinus discharging pus formed exposing the graft. Infected PTFE graft was excised. A rim of graft was left proximally to avoid injury. Early excision of infected synthetic grafts with or with out another bypass can avoid further complications.

Aneurysm with aortic stenosis just distal to the origin of the left subclavian artery in thoraic aorta.

Patients will be waiting for long time with symptoms before they come to the major hospitals with large aneurysms of this size due to various reasons. In addition to the socio-economic reasons they also fear that the operations are not safe in the hospitals. When are grown to this size as there is no alternative they come to hospitals in prerupture syndrome. The results in such patients with prerupture or rupture of the thoracic aneurysms the results are critical supporting their fears. We need to develop a aneurysm central registry to help these patients with the initiative of the government. The national surgical and medical associations can be given this responsibility by the government or medical council of India.

Radial artery Aneurysm in a young man working in bar

Glass bottle or glass piece injuries to the forearm can easily injure the radial artery which is superficial and close to the bone. The local pressure can stop the bleeding and it may result in thrombosis of the radial artery without any problems. But in some it can recanalize and later present as pseudoaneurysm ( 2-3 months) as in this case. It will be tender to touch and starts expanding after that. In this patient the ulnar artery is palpable and it is providing the major blood supply to the palm. Simple excision of the aneurysm and repair of the radial artery is required. Some times one may argue that ligation of the radial artery proximal and distal to the aneurysm may be sufficient to releive the symptoms.

Are we still seeing Buerger's disease (TAO)?

we used to see more patients with gangrenous tips due to excessive smoking in young people 15 years back. Then slowly the number of such patients attending our clinic slowly decreased. But in the recent past again we are finding more of them coming to our clinics. It is probably due to the Aarogyasri scheme which is providing them financial support to come to the big hospitals for special care. The disease presentation in the hospitals is dependent on many aspects and one may get misguided if the disease presentation is not understood. Buerger's disease still persists in our low socioeconomic group of people.

Synthetic graft for replacing the diseased common femoral artery and superficial femoral artery in the groion with implantation of the profunda femoris artery.

Young smokers usually present to the vascular clinics from the rural areas with disease below the knee and above the knee. Such patients may need repair of the thigh blood vessels with poor distal runoff below the knee. One would be heistantly usin the synthetic grafts in them as there is no other alternative to the diseased veins (graft). In such cases we feel it is very important to make sure the profundafemoris branch is revascularised (with or without endarterectomy) by reimplanting it in to the synthetic graft. This will probably help also in improving the patency of the synthetic graft. This video was taken after completion of the operation where the profunda is attached to the graft ( hidden) in graft bed.

Pinjal R K '09

Carotid body Tumor in a father and daughter

Carotid body tumors are uncommonly seen in the clinical practice. Many times, when they are small in size they are mistaken as the lymphnodes in the neck. Some times people consider biopsies suspecting tuberculosis or other patholgies. attempted. Carotid body tumors are also seen in the families, like in this photo a father and daughter are seen with tumors.

World No Tobacco Day - May 31st 2009
100 million people lives are at risk due to the use of tobacco.
In India, 25ooo are killed by bad effects of tobacco. It is important that fact is recognized and people should act. The govt has taken a stand by banning smoking in the public places. But public should take interest and avoid the death due to the side effects of smoking. 70% of the tobacco users in India are smoking bidis. we need to educate the commo man now to avoid the tobacco and there should be special monitoring programs for the tobacco control actions by the government like we have for Tuberculosis, HIV and Malaria. This is very important to avoid the cancers, cardiovascular problems in the society.
Pinjala R K

Large Abdominal Aortic Aneurysm

In many hospitals, large aortic aneurysms are diagnosed after an initial ultrasound examination which is later confirmed on CT scanning

Excision of Thrombosed
Varicose Veins
Thrombosis of the varicose veins may induce local inflammatory symptoms with bulging and pain. Local pigmentation over the thrombosed veins is also common. Medical therapies, compression bandages may relieve the symptoms during course of 2-3 weeks. There is a possibility that the same thrombosis may also recur again in some patients after recanalization. Surgical excision of the thrombosed varicose veins along with neighboring varicose veins with reflux will facilitate early recovery without any major risk of pulmonary embolism. It would be necessary to consider Thrombo-prophylaxis with LMWH in the peri-operative period.

Leiomyosarcoma from vein wall

Tumors from the vessel walls are rare. Leiomyosarcoma from the Iliac vein wall can present as mass, deep vein thrombosis. Complete excision is the best possible treatment for them. Reconstruction of the resected is to be considered if possible. Usually these grafts may get thrombosed after some time without any problems due to the development of collateral veins. Prognosis is poor if there are metastasis to the liver and lung. Their 5 yr survival is reported to 32%. Till now less than 100 cases of leiomyosarcoma were reported from extremity veins.

Two Post graduates from Dept of Vascular surgery, Chennai General Hospital - visiting (Fellowship) Nizam's Institute of Medical Sciences, Hyderabad, AP, India

We are pleased to invite the postgraduates in vascular surgery from Chennai general hospital to visit our department. There are very few centres training vascular surgeons in our country. Nizam's Institute of Medical Sciences has been imparting training to the vascular surgeons for the past 20 years. The department of vascular surgery is adequately supported by all the other sub-specialities. The common man is able to get specialized vascular surgical services. The young surgeons are able to get an opportunity to see different presentations of vascular disease and classical and special treatments provided to these patients. All those doctors who were trained in this department are now independently practicing vascular surgery in differrent parts of India.

Superior venacaval Syndrome - Is prognosis really worse in these patients? Why?

The prognosis is dependent the etiology of the obstruction and rate of progression of the underlying disease. More than 75% the SVC syndrome cases are associated with some form of malignancy and so the prognosis is perceived as poor. If SVC obstruction is secondary to benign condition then the prognosis is better.

Pinjala RK

VAICON 2009 at Hyderabad

In this 2nd Annual conference of the Venous Association of India 225 delegates participated the conference. Pre-Conference CME was organized for Doctors, Nurses and Physiotherapists on 23rd January at NIMS, Learning center for 200 participants. The Nurses and Nursing students organized exhibition on various types of Venous disorders and all of them participated with lot of enthusiasm. The senior delegates who went round to see the charts exhibited by the nurses, heard their presentations and deeply appreciated their talent and hard work.

The conference on 24th , 25th of January at Hotel FORTUNE SELECT MANOHAR was attended by participants from different parts of India and abroad. All the participants appreciated the scientific content of the conference, arrangements and hospitality extended by the organizing committee and made it a successful conference.
The new executive committee was formed for the Venous Association of India. New members were inducted in to the excutive committee.

The venue for the "VAICON 2010" is going to be Bangalore and will be organized by Dr. Vasudeva Rao from Manipal Hospital.

An Invitation was extended to all participants to become the members of the Venous Association of India and participate in all the events organized by venous association of India.

(More details on the scientific presentations will be posted later)

Prof Pinjala Ramakrishna, MS,FRCSEd
VENOUS ASSOCIATION OF INDIA
26th Jan 2009

9th Jan 2009

VAICON 2009 - Hyderbad on 24,25th Jan2009 and the CME on 23rd at NIMS learning center.

We are inviting all the post graduates, nurses with special interest in the venous disorders to participate in the CME to learn more about the venous disorders. Varicose veins, DVT, Venous ulcers are still common problems in our hospitals. They are better understood and better cared in the past few years. This is helping our patients to get better relief and prevent recurrences of the venous problems with adequate therapies and preventive measures. -- Pinjala R K

Dysphagia in association with Thoracoabdominal aneurysm of the Aorta

Thoracoabdominal aneuryms (TAAA)which are close to esophagus may produce extrinsic compression of esophagus. It will be seen as a smooth bulge during the
during the endoscopy. Manometric studies were found to be abnormal in these patients. In this endoscopic photograph (see the attached image) the mucosal swelling and ulceration is seen near the site of extrinsic compression. Endoscopic ultrasonography has shown gas bubbles in the wall of the esophagus. Patient was able to swallow liquids only. Such types of comression of esophagus was managed some times by medical meaures in elderly woman (>84 years) successfully. But it would need attention and intervention to releive the compression in the youger and middle aged people. We have recently managed another patient with absolute dysphagia associated with TAAA. He required Total parenteral nutrition before the Endovascular repair of the TAAA. His ability to swallow improved after the Endorepair with Endograft due to the relief of pressure over the esophagus by the TAAA.
By
Pinjala R K

Affect of the “Tibial-arterial disease” on the outcomes in leg vascular disease patients

The lower limb arterial system is divided in to 3 segments for better understanding of the disease and also for planning various therapeutic options. Aorto-iliac, Femoro-popliteal and Tibio-peroneal diseases are three zones. However the quantity of the disease is not measured accurately for the routine clinical purposes. Therefore comparing the out comes of procedures performed on patients with different degrees of functionally active and mechanical disease. The failure rates of infra popliteal revascularization are high across all the countries irrespective of their methods of revascularization.The determining factors seem to be diabetes and history of prior tissue loss or gangrenous changes.In the routine clinical practice it is important to grade the tibial vessel disease which is often missed. In the post operative period one tries to look for the Doppler signals and palpable pulses which may be or may not be good enough for the relief of symptoms over a long period of time.

In a recent paper published -Multivariable analysis demonstrated tobacco use, renal disease, diabetes, and tissue loss are all predictors of patency loss, while only diabetes and tissue loss were associated with greater limb loss. There was no difference in patency rates irrespective of location of Trans Atlantic Inter-Societal Consensus (TASC) classification, vessel treated (femoral vs tibial), or degree of stenosis (occluded vs stenotic). Also, multiple vessels treated in the same patients had no affect on patency. The mean ankle brachial index (ABI) pre-op was 0.57 +/- 0.19, and this increased to 0.81 +/- 0.21 (P < .001) at 30 days post-op. CONCLUSION: Lower extremity atherectomy procedures with the SilverHawk device are safe and effective means in improving symptoms. However, there is decreased durability and significant patency and limb loss over time. Diabetes, renal disease, tobacco use, and tissue loss are all associated with inferior outcomes.

Reference:

Sarac TP et al, J Vasc Surg. 2008 Oct; 48(4):885-90

Midterm outcome predictors for lower extremity atherectomy procedures. Sarc TP et al
Department of Vascular Surgery, The Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA.

Atherectomy in the lower limb arteries
Is there a future for this procedure in getting better limb salvage ?

Laparoscopic Vascular injuries at the level of Iliac artery (Pelvis) can be life threatening due to pelvic and retroperitoneal bleeding.

In the recent past 3 patients with iliac artery injury were referred from the peripheral hospitals for management. In these there has been difficulty in sending to the concerned specialist centers very late due to logistics. In all the three patients an attempt was made by the general surgeons to control the bleeding but it also resulted in systemic problems and distal limb ischemia (Acute). In one patient there was iliac vein thrombosis in addtion to the arterial injury. One patients required femoro-femoral corss over graft ( tubectomy patient) , 2nd patient required direct repair of the iliac artery ( plus appendicectomy) and 3rd patient required Aortofemoral bypass (+Tuberculous adhesiolysis). In all the three patients the limb was salvaged.

Large Venous Malformations in the Neck -

Are they curable with the available therapies?

Open surgeries, endovascular therapies and other plastic surgical procedures?

Large Venous malformations in the Head neck region are associated with complex hemodynamics and anatomy. Imaging these lesions adequately is difficult and planning interventions in multiple stages may be expensive and tiring to the family and providers. In addition the procedures are associated with hidden complications. Probably one would like to hear about the possibility of genetic therapies for such large lesions with intra thoracic ramifications and communications with other large veins in the head and neck region.